A small case-load is becoming one of the shibboleths of community
psychiatry. The paper by Burns et al
(2000, this issue) focuses on
this matter with a comparison of two models of service delivery in recurrent
psychotic illness: intensive and standard case management. The main difference
between these two models was the case-load per key-worker; those in intensive
case management (ICM) had no more than 15 per keyworker whereas standard case
management (SCM) had case-loads of between 30 and 35. In addition, however,
those in the intensive management service also received a brief course of
training in the Boulder Community Support System (CSS) model of care; this
shows similarities with assertive community treatment (ACT) practised
elsewhere in the USA (Stein & Santos,
1998, p. 33).

The results of the study may at first sight be unexceptional. Those
allocated in the randomised trial to ICM received more input from all sources,
both directly and indirectly, than those allocated to SCM. This was
particularly marked for face-to-face contacts with the patients concerned and
even more so for failed face-to-face contacts, most of which were attempted at
the patient's home. The significance of the findings becomes greater when one
considers other findings from the UK700 Group and the general policy context
of ACT. The main question the findings pose is why the greater frequency of
contact in ICM was not translated into any clinical improvement with regard to
either the primary outcome (duration of in-patient psychiatric treatment
during the study) or a range of secondary outcomes, including the specific one
that improvement with ICM might be more effective in those of
African-Caribbean ethnicity (UK700 Group,
1999a). This has been the subject of recent
correspondence in the Journal about another study that showed no
benefit of ICM and, for some variables, showed superior benefit with SCM
(Thornicroft et al,
1998; Wykes et al,
1998). The contradiction between the findings in these studies and
those from other parts of the world, notably Australia and the USA, has led to
questions about fidelity to the model, possible differences in core services
in the countries concerned and, as the authors argue in their paper, the
possibility that the care model may have been followed faithfully but was not
necessarily using successful (evidence-based) interventions.

FIDELITY TO THE MODEL

It is difficult to be certain what constitutes the essential components of
ICM. Assertive community treatment comprises six essential features:
case-loads of no fewer than 8 and no more than 12 per keyworker, an integrated
team structure with at least three professional disciplines, no more than 20%
of staff part-time, 24-hour availability, team autonomy and (an important
consideration) part-time psychiatrist input only
(Stein & Santos, 1998, pp.
64-65). Intensive case management in Burns et al's study did not
satisfy all these requirements. The upper case-load was slightly higher than
allowed in ACT, none of the teams operated a 24-hour service (the services
outside normal hours were provided equivalently for standard and intensive
teams) and frequency of contact, averaging once every 9 days in the intensive
team, was much less than ACT and CSS studies recommend
(Stein & Santos,
1998).

However, some of these differences may be related to different policies in
different countries. Home treatment and depot injections are more common in
the UK than in the USA. In ACT and CSS teams in the USA it is commonplace for
patients to receive oral medication and to attend daily for administration and
monitoring purposes and this makes it much easier for the team to monitor than
if they regularly saw such patients at home. The presence of 24-hour cover is
also not as important in the UK as in the USA. Because there is often no real
health cover available for these patients in the USA it is easy to see why it
was necessary to set up a telephone contact system. However, as there is
comprehensive 24-hour cover in almost all areas of the UK for psychiatric
emergencies, it is not often justified to set up separate cover for an
intensive team.

Taken together, it does not look as if the differences between ICM in the
UK700 study and elsewhere are sufficient to explain the negative findings of
the intensive model. It is also argued that a good assertive team takes time
to establish and that this would apply to ICM also. In the UK700 study, three
of the four centres involved new teams set up specifically for the purposes of
the research and it could be argued that these had not been sufficiently well
integrated to provide good intensive care. However, this criticism is to some
extent countered by the fact that the team with the most ICM experience and a
proven record of success, that of St George's Hospital (Burns et al,
1993a,
b), also showed no
superiority over SCM despite having a greater frequency of face-to-face
contact than the other two intensive teams.

DIFFERENCES IN STANDARD CARE

Unlike drug treatment, psychosocial treatments have a habit of taking on
the good elements of fellow treatment approaches quietly, almost by stealth,
and in the UK we have long had a pragmatic approach to community care which
could be called ACC, or assertive community creep. Although the proponents of
assertive treatment argue that it has revolutionised the care of the severely
mentally ill in the USA, it holds no patent on its key elements and many of
them have been used to good effect long before ACT and ICM became fashionable
acronyms. In the UK we have long been aware of the negative aspects of care in
state mental institutions (Lomax,
1921) and of the benefits of early intervention and assertive
contact with patients at home (MacMillan,
1963; Sainsbury et
al, 1966). The UK also did not make the mistake of imitating
the experiment of the community mental health centre movement in the USA in
the 1960s that really led to the conditions ripe for the birth of ACT, a
dearth of satisfactory community services for those with severe mental
illness. From the early 1970s onwards, community mental health teams, often
consisting of only two disciplines, nurses and psychiatrists, have developed
in many countries and, to varying degrees, have quietly taken on the type of
service that has been promoted quite aggressively in recent years by the ACT
movement.

It is therefore not surprising that comparisons of the new treatment model
with a standard model containing some of its key elements are not going to
show the same benefits as when the standard treatment contains none of these
elements. This is demonstrated by Burns et al
(2000, this issue) in their
paper, in which the differences between each limb of the psychiatric service
are quantitative rather than qualitative in nature. It therefore behoves
researchers in future studies of these models to define ‘standard’
more precisely.

ABSENCE OF EVIDENCE-BASED INTERVENTIONS

The argument that both ICM and SCM teams might well have delivered the same
evidence-based interventions to the patients under their care, accounting for
the absence of significant difference between the models, is a powerful one.
Additional face-to-face contacts are not therapeutic in themselves, although
much of the literature on the subject may imply this. A simple question such
as ‘Does intensive case management improve compliance with
medication?’ cannot be answered from most studies comparing these
models, and the UK700 study is no exception. We have no evidence that new
interventions that have good evidence of their efficacy and durability in
psychotic disorders (e.g. Kemp et al,
1996,
1998;
Perry et al, 1999;
Tarrier et al, 1999)
are being used, and these should be compared in future studies rather than all
our attention being focused on the management elements of care.

NEGATIVE INFLUENCES OF ICM

This question is not a heretical one. There must come a point at which
persistently striving to keep a patient out of hospital becomes an
inappropriate aim, both clinically and economically. Only the most fanatical
of community treatment enthusiasts argue that psychiatric beds are unnecessary
and no one has successfully achieved a bedless service for the severely
mentally ill. It is interesting that the UK700 study demonstrated powerful
benefits in favour of ICM compared with SCM for one important group - those
with recurrent psychosis and borderline learning disability, who comprise just
under one in seven of the total sample
(UK700 Group, 1999b).
This population shows important differences from those with an IQ within the
normal range (Hassiotis et al,
1999) and they may be helped more by this approach because they
have greater difficulty in expressing their needs and may require a more
assertive approach to all parts of their care. Those within the normal IQ
range may find frequent contacts intrusive, particularly if they occur at
home, and react adversely. One of the unexpected findings in the main UK700
study (UK700 Group,
1999a) was that those in ICM were significantly more
likely to lose contact with their case manager than those in the SCM teams.
This is in keeping with the above hypothesis. More needs to be done to ensure
better adherence to treatment plans that prevent loss of contact from care,
for although contact is the main asset of the Care Programme Approach
(Tyrer et al, 1995)
it could go much further. It may require lessened focus on face-to-face
contacts; in the UK700 study a marked reduction in the frequency of these was
seen over time in the St Mary's team that was successfully transferred to a
liaison role (Weaver,
2000).

Against this raft of negative evidence it is surprising that the UK
Government continues to promote assertive outreach (an odd term that does not
have a clear definition) as the recommended way forward for the community care
of those with severe mental illness (Department of Health,
1998,
1999). The good news that
should be promoted across the country is that good sectorised community mental
health teams, despite the battering they often unfairly receive in government
inquiries, constitute a robust method of delivering good-quality care and that
it is these, rather than imported models of service delivery, that should be
the focus of our praise.